Attachment and Loss VOLUME III LOSS SADNESS AND DEPRESSION John Bowlby A Member of the Perseus Books Group -iii- Copyright © 1980 by The Travistock Institute of Human Relations Published by Basic Books, A Member of the Perseus Books Group All rights reserved. Printed in the United States of America. No part of this book may be reproduced in any manner whatsoever without written permission except in the case of brief quotations embodied in critical articles and reviews. For information, address Basic Books, 10 East 53rd Street, New York, NY 10022-5299. Library of Congress Catalog Number: 79-2759 ISBN o-465-04237-6 (cloth) ISBN o-465-04238-4 (paper) 10 9 8 7 6 5 4 3 2 1 -iv- TO MY PATIENTS who have worked hard to educate me -v- 2 Contents Foreword xiii Acknowledgements xvi Preface 1 Part I: Observations, Concepts and Controversiesi 1 The Trauma of Loss 71 Prelude 71 Grief in infancy and early childhood 9 Do young children mourn? a controversy 14 Detachment 19 2 The Place of Loss and Mourning in Psychopathology 231 A clinical tradition 23 Ideas regarding the nature of mourning processes, healthy and pathological 24 Ideas to account for individual differences in response to loss 34 3 Conceptual Framework 38 Attachment theory: an outline 38 Stressors and states of stress and distress 41 4 An Information Processing Approach to Defence 44 A new approach 44 Exclusion of information from further processing 44 Subliminal perception and perceptual defence 46 Stages at which processes of defensive exclusion may operate 52 Self or selves 59 3 Some consequences of defensive exclusion 64 Conditions that promote defensive exclusion 69 Defensive exclusion: adaptive or maladaptive 72 5 Plan of Work 75 -vii- Part II: The Mourning of Adults 6 Loss of Spouse 81 Sources 81 Four phases of mourning 85 Differences between widows and widowers 103 Note: details of sources 106 7 Loss of Child 112 Introduction 112 Parents of fatally ill children 113 Parents of infants who are stillborn or die early 122 Affectional bonds of different types: a note 124 8 Mourning in Other Cultures 126 Beliefs and customs common to many cultures 126 Mourning a grown son in Tikopia 132 Mourning a husband in Japan 134 9 Disordered Variants 137 Two main variants 137 Chronic mourning 141 4 Prolonged absence of conscious grieving 152 Mislocations of the lost person's presence 161 Euphoria 169 10 Conditions Affecting the Course of Mourning 172 Five categories of variable 172 Identity and role of person lost 173 Age and sex of person bereaved 178 Causes and circumstances of loss 180 Social and psychological circumstances affecting the bereaved 187 Evidence from therapeutic intervention 195 11 Personalities Prone to Disordered Mourning 202 Limitations of evidence 202 Disposition to make anxious and ambivalent relationships 203 Disposition towards compulsive caregiving 206 Disposition to assert independence of affectional ties 211 Tentative conclusions 222 12 Childhood Experiences of Persons Prone to Disordered Mourning 214 Traditional theories 214 The position adopted 216 Experiences disposing towards anxious and ambivalent attachment 218 Experiences disposing towards compulsive caregiving 222 Experiences disposing towards assertion of independence of affectional ties 224 13 Cognitive Processes Contributing to Variations in Response to Loss 229 A framework for conceptualizing cognitive processes 229 Cognitive biases affecting responses to loss 232 5 Biases contributing to chronic mourning 234 Biases contributing to prolonged absence of grieving 239 Biased perceptions of potential comforters 240 Biases contributing to a healthy outcome 242 Interaction of cognitive biases with other conditions affecting responses to loss 243 14 Sadness, Depression and Depressive Disorder 245 Sadness and depression 245 Depressive disorder and childhood experience 246 Depressive disorders and their relation to loss: George Brown's study 250 The role of neurophysiological processes 261 Part III: The Mourning of Children 15 Death of Parent during Childhood and Adolescence 265 Sources and plan of work 265 When and what a child is told 271 Children's ideas about death 273 16 Children's Responses when Conditions are Favourable 276 Mourning in two four-year-olds 276 Some tentative conclusions 285 Differences between children's mourning and adults' 290 Behaviour of surviving parents to their bereaved children 292 17 Childhood Bereavement and Psychiatric Disorder 295 Increased risk of psychiatric disorder 295 Some disorders to which childhood bereavement contributes 300 18 Conditions Responsible for Differences in Outcome 311 Sources of evidence 311 Evidence from surveys 312 6 Evidence from therapeutic studies 317 19 Children's Responses when Conditions are Unfavourable 320 Four children whose mourning failed 320 Peter, eleven when father died 321 Henry, eight when mother died 327 Visha, ten when father died 333 Geraldine, eight when mother died 338 20 Deactivation and the Concept of Segregated Systems 345 21 Disordered Variants and Some Conditions Contributing 350 Persisting anxiety 351 Hopes of reunion: desire to die 354 Persisting blame and guilt 358 Overactivity: aggressive and destructive outbursts 361 Compulsive caregiving and self-reliance 365 Euphoria and depersonalization 370 Identificatory symptoms: accidents 376 22 Effects of a Parent's Suicide 381 Proportion of parents' deaths due to suicide 381 Findings from surveys 382 Findings from therapeutic studies 383 23 Responses to Loss during the Third and Fourth Years 390 Questions remaining 390 Responses when conditions are favourable 390 Responses when conditions are unfavourable 397 24 Responses to Loss during the Second Year 412 7 A transitional period 412 Responses when conditions are favourable 412 Responses when conditions are unfavourable 416 25 Young Children's Responses in the Light of Early Cognitive Development 425 Developing the concept of person permanence 425 The role of person permanence in determining responses to separation and loss 433 Epilogue 441 Bibliography 443 Author Index 463 Subject Index 467 -xi- 8 Foreword John Bowlby's work has profoundly marked the second half of the twentieth century. It has brought about what is probably the most important and far-reaching shift in our perspective and direction of inquiry in the field of early human development. Bowlby's own perspective on attachment and loss derived from several sources--classical psychoanalysis, object relations theory as practiced by the British school, ethology, and evolutionary biology-none of which alone could have prefigured the central place of attachment in early social-emotional development. Accordingly, the path by which attachment theory has come to be accepted was not direct; its initial impact on the psychoanalytic community and clinical psychology in general was modest--disappointing, in fact, since these disciplines were dearly pivotal in Bowlby's mind. Attachment theory instead entered the psychological mainstream through the door of developmental psychology, thanks in large part to the observational and experimental work of Mary Ainsworth and two generations of her students. Only later, after it had accumulated a body of convincing empirical data did attachment theory become a central concept in all clinical psychologies. Today it seems incredible that until Bowlby no one placed attachment at the center of human development, thereby facilitating a satisfying approach to the issue of separation and loss. Inded, before Bowlby, there had been a gaping omission in evolutionary and psychoanalytic theory: two basic motivational systems were postulated, one for assuring the self-survival of individuals so that they could reproduce, and one that led them to do so; the perpetuation of the gene pool therefore was not in doubt--but how did a baby stay alive long enough for these systems to kick in and do him or her much good? The magnitude of Bowlby's contribution is that attachment theory identified a new basic motivational system to account for the missing link in the intergenerational chain. -xiii- The impact of Bowlby Attachment and Loss on psychoanalytic theory and practice is gaining. The road has been harder because attachment theory challenges many basic tenets of psychoanalytic developmental theory. To cite just a few: attachment theory, emphasizing the first years of life, gives relatively more importance to the pre-oedipal period in determining later development and pathology; attachment theory insists that its fundamental motivational system is not derivative from other basic instincts but is basic in its own right; attachment theory has begun to diminish the role of the psychosexual stages of development as it replaces their explanatory power; attachment theory has given a new and different impetus to the exploration of the representational world of the infant. 9 In short, attachment theory has had an uphill fight against existing psychoanalytic theories, and a downhill ride filling in gaps in most other clinical psychologies. Regardless, attachment theory has become the paradigm in considering not only early pathology but also our understanding of the human responses to separation and loss. This volume, already a classic, is a cornerstone in the construction of attachment theory and its implications. Daniel N. Stern, M.D. Geneva, October 1999 -xiv- Acknowledgements Once again in preparing this volume I have been helped and encouraged by many friends and colleagues who have given most generously of their time and thought. To all of them I am deeply grateful. One to whom I am especially indebted is Colin Murray Parkes. At a time in the early nineteen-sixties when I was struggling to clarify the nature of mourning he drew my attention to Darwin's ideas and to the part played by the mourner's urge to recover the lost person. Subsequently we joined forces and he began his studies of widows, first in London and later in Boston, which have made such a big contribution to our understanding. He has read through the chapters in Part II of this volume, on the mourning of adults, and has made a large number of valuable criticisms and suggestions.